ELK GROVE VILLAGE, ILL--The American Academy of Pediatrics (AAP) has issued its 2000 Red Book: Report of the Committee on Infectious Diseases.[1] Published every three years, the Red Book contains comprehensive guidelines for the control of infection in pediatric patients. This 25th edition features major changes in the AAP's recommendations for the management of specific diseases, including a variety of respiratory infections.

RESTRICTING ANTIMICROBIAL USE

A new section in the 2000 Red Book emphasizes judicious use of antimicrobial agents to combat the spread of resistant organisms. Restrictions on antimicrobial use are particularly important for upper respiratory tract infections; about three quarters of all pediatric outpatient prescriptions are written for these. The following are the AAP's recommendations:

Otitis media: Antibiotic therapy is appropriate when documented middle ear effusion is accompanied by manifestations of acute local or systemic disease. However, persistent middle ear effusion does not require antibiotic treatment unless it has lasted for three months or more. Prophylactic antibiotics are reserved for patients who have had three or more episodes of acute otitis media within six months or four or more episodes within 12 months.

Acute sinusitis: A clinical diagnosis of bacterial sinusitis requires nasal discharge and daytime cough that do not improve for 10 to 14 days, facial swelling and pain, and a temperature of 39°C (102°F) or higher. The antibiotic selected should have the narrowest spectrum that is active against the likely pathogens.

Cough illness/bronchitis: Antimicrobial treatment is rarely appropriate for nonspecific cough illness/bronchitis in children, regardless of the disease duration. However, such treatment may be indicated for cough lasting more than 10 to 14 days if infection with Bordetella pertussis or Mycoplasma pneumoniae is present. Children with underlying chronic pulmonary disease other than asthma may respond to antimicrobial therapy during acute exacerbations.

Pharyngitis: Children with pharyngitis should not receive antibiotics unless a bacterial pathogen (especially group A streptococcus) is identified. Penicillin remains the drug of choice for group A streptococcal infections.

Common cold: Antimicrobial agents are not indicated for the common cold. However, mucopurulent rhinitis that persists for 10 to 14 days suggests the possibility of sinusitis, in which case antimicrobial therapy is justified.

The AAP acknowledges that parents may sometimes try to pressure physicians into prescribing antimicrobial agents inappropriately. But the 2000 Red Book warns: "Children treated with an antimicrobial agent are at increased risk of becoming carriers of resistant bacteria.… Carriers of a resistant strain who develop illness from that strain are more likely to fail antimicrobial therapy."

COMMON CHILDHOOD INFECTIONS

Among the childhood illnesses for which updated recommendations have been made are pertussis, influenza, and respiratory syncytial virus infection. New information has also been provided for the management of staphylococcal and streptococcal infections.

Pertussis: A 14-day course of erythromycin is still preferred for most children with pertussis. Although erythromycin administration to children younger than 6 weeks of age has been linked to the development of infantile hypertrophic pyloric stenosis (IHPS), the drug is still preferred for two reasons:

1) Additional studies are needed to confirm that erythromycin causes IHPS, and

2) The efficacy of alternative treatments for pertussis remains unproven.

Only acellular pertussis vaccines should be used during routine childhood immunization; whole cell pertussis vaccines are no longer recommended, according to the AAP's recent report.

Influenza: The effectiveness of both amantadine and rimantadine for the treatment of influenza A infection in children appears to be similar to that found in adults; however, only amantadine has a pediatric treatment indication. Both drugs are approved for the prevention of influenza A in children, but neither is effective against influenza B.

In addition, two neuraminidase inhibitors have been approved for the treatment of uncomplicated influenza A and B. Zanamivir, an inhalant, can be given to children age 7 years and older, whereas oseltamivir is indicated for patients age 18 years or older. (Note: The use of zanamivir in children between the ages of 7 and 11 was approved after the 2000 Red Book went to press.)

Only split-virus vaccines should be given to children younger than age 13. Two doses of the vaccine, administered one month apart, are necessary for children under age 9 years who are receiving influenza vaccine for the first time.

Respiratory syncytial virus (RSV) infection: Treatment is primarily supportive; whether ribavirin administration is helpful remains controversial. However, progress has been made in prevention. A new prophylactic agent, palivizumab, has been approved; it is administered intramuscularly once a month during the RSV season. The drug should be considered for children younger than 2 years with chronic lung disease and also for premature infants. Intraveneously administered RSV immune globulin can also be used for prevention; however, palivizumab is preferred because of its ease of administration, safety, and effectiveness.

Staphylococcal infections: In the past two decades, the incidence of coagulase-negative staphylococcal infections has increased steadily. Resistance to coagulase-negative staphylococci, and to Staphylococcus aureus, has also risen markedly. Because these organisms are resistant to all ß-lactams (and to many other antibiotics as well), treatment must be carefully selected. Options include a penicillinase-resistant penicillin, a first- or a second-generation cephalosporin, or clindamycin. Vancomycin should be reserved for drug-resistant strains and for patients who are allergic to penicillin. Topical antibacterial therapy should be considered for localized, superficial skin lesions.

Non-group A or B streptococcal/enterococcal infections: A new drug, quinupristin-dalfopristin, is available for the treatment of vancomycin-resistant Enterococcus faecium infection; it is not effective against E faecalis. Optimum treatment for severe infections due to groups C, F, and G may require a combination of ampicillin and gentamicin. Penicillin G or ampicillin alone is appropriate for other infections.

SPECIAL SITUATIONS

Pneumocystis carinii pneumonia: Recommendations for managing P carinii pneumonia have been updated to conform with guidelines developed by the United States Public Health Service and the Infectious Diseases Society of America. Currently, the drug of choice is intravenous trimethoprim-sulfamethoxazole. Oral therapy may be appropriate in children with mild disease who do not show signs of malabsorption or diarrhea.

About 15% of HIV-infected children treated with trimethoprim-sulfamethoxazole experience adverse reactions. Continuation of therapy is recommended in children with mild reactions, however, because 50% of these patients subsequently have successful outcomes with this drug. In children who are either intolerant of or unresponsive to trimethoprim-sulfamethoxazole, an alternative is parenteral pentamidine.

Hantavirus cardiopulmonary syndrome (HPS): New to the 2000 Red Book is a chapter on HPS. The guideline recommends that children diagnosed with HPS be immediately transferred to a tertiary care facility, because supportive management during the first 24 hours is critical for recovery. Intravenous ribavirin may help reduce mortality. Short-term use of extracorporeal membrane oxygenation is recommended to provide support for the severe capillary leak syndrome in the lungs.

--Stanley Nelson

Reference
1. Pickering LK, Peter G, Baker CJ, et al. Red Book 2000: Report of the Committee on Infectious Diseases. 25th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2000.

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